Academic stands by research querying Indonesia's claim to be coronavirus-free

Karen McVeigh and Emma Graham-Harrison
Photograph: Ajeng Dinar Ulfiana/Reuters

A Harvard academic has defended research suggesting a possible underreporting of coronavirus cases in Indonesia, following fierce criticism from the health minister in the world’s fourth most populous country, which insists it has no cases.

Professor Marc Lipsitch analysed air traffic out of the Chinese city at the centre of the outbreak in China and suggested in a report last week that Indonesia might have missed cases. On Tuesday the Indonesian health minister Terawan Agus Putranto called the report “insulting” and said the country had proper testing equipment.

On Thursday, health officials in Indonesia, which has a population of 272 million and is a popular destination for Chinese tourists, said they were retracing the movements of a Chinese tourist who was diagnosed with coronavirus upon his return from Bali. No-one in Bali has yet been found with symptoms.

The World Health Organization said earlier this month it was particularly concerned about high-risk nations with weaker health systems that may lack the facilities to identify cases.

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Lipsitch, from the Center for Communicable Disease Dynamics at the Harvard TH Chan School of Public Health, co-authored a paper that found several locations including Indonesia, Cambodia and Thailand where the number of cases were below the levels expected. “We stand by our research,” he said. “I certainly do not intend it as an insult to any country or person. The role of public health is to spot potential problems and to point them out.”

He said three unlinked cases in neighbouring Singapore – an “expert” country at contact tracing – had increased concern similar transmission was happening under the radar elsewhere.

What is the virus causing the illness that started Wuhan?

The virus is officially called Sars-CoV-2 and this causes the disease Covid-19. It is a member of the coronavirus family that has never been encountered before. Like other coronaviruses, it has come from animals. Many of those initially infected either worked or frequently shopped in the Huanan seafood wholesale market in the centre of the Chinese city.

What other coronaviruses have there been?

New and troubling viruses usually originate in animal hosts. Ebola and flu are other examples – severe acute respiratory syndrome (Sars) and Middle Eastern respiratory syndrome (Mers) are both caused by coronaviruses that came from animals. 

What are the symptoms of the coronavirus?

The virus can cause pneumonia. Those who have fallen ill are reported to suffer coughs, fever and breathing difficulties. In severe cases there can be organ failure. As this is viral pneumonia, antibiotics are of no use. The antiviral drugs we have against flu will not work. If people are admitted to hospital, they may get support for their lungs and other organs as well as fluids. Recovery will depend on the strength of their immune system. Many of those who have died were already in poor health.

Is the virus being transmitted from one person to another?

China’s national health commission has confirmed human-to-human transmission, and there have been such transmissions elsewhere. As of 12 February there are now 45,182 confirmed cases and 1,115 deaths. There are cases in 28 other countries outside China, with deaths recorded in one case in Hong Kong, and one case in the Philippines. The number of people to have contracted the virus overall could be far higher, as people with mild symptoms may not have been detected.

The number of confirmed cases of coronavirus in the UK has doubled from four to eight after four more people in Brighton were diagnosed with the infection over the weekend.

There are nine cases of the virus in the UK. Four were located in Brighton, one in London. At Arrowe Park Hospital in Merseyside 83 people in quarantine were told they would be allowed to leave on Thursday after they all tested negative. Of the 1,750 tests carried out so far in the UK, more than 99% had been negative.

Why is this worse than normal influenza, and how worried are the experts?

We don’t yet know how dangerous the new coronavirus is, and we won’t know until more data comes in. The mortality rate is around 2%. However, this is likely to be an overestimate since many more people are likely to have been infected by the virus but not suffered severe enough symptoms to attend hospital, and so have not been counted. For comparison, seasonal flu typically has a mortality rate below 1% and is thought to cause about 400,000 deaths each year globally. Sars had a death rate of more than 10%.

Should I go to the doctor if I have a cough?

Unless you have recently travelled to China or been in contact with someone infected with the virus, then you should treat any cough or cold symptoms as normal. The NHS advises that people should call 111 instead of visiting the GP’s surgery as there is a risk they may infect others.

Is this a pandemic and should we panic?

Health experts are starting to say it could become a pandemic, but right now it falls short of what the WHO would consider to be one. A pandemic, in WHO terms, is “the worldwide spread of a disease”. Coronavirus cases have been confirmed in about 25 countries outside China, but by no means in all 195 on the WHO’s list.

There is no need to panic. The spread of the virus outside China is worrying but not an unexpected development. The WHO has declared the outbreak to be a public health emergency of international concern, and says there is a “window of opportunity” to halt the spread of the disease. The key issues are how transmissible this new coronavirus is between people and what proportion become severely ill and end up in hospital. Often viruses that spread easily tend to have a milder impact.

Sarah Boseley Health editor and Hannah Devlin 

A leading hypothesis for the lack of reported cases in Indonesia is that imported cases were missed, said Lipsitch, who pointed to a Sydney Morning Herald report that the country had no test kits until 5 February in support of the theory.

“If cases have been introduced into Indonesia, then there is a good chance that more cases are circulating via transmission from those cases. If so, they may go undetected for some weeks as the individuals may not seek care or may not be suspected and tested for coronavirus, especially if there is no direct link to China.”

Putranto told reporters in Jakarta earlier this week: “They can be baffled but it’s a fact [that there are no cases]”. The former military doctor was reprimanded in January by the Indonesian Medical Association Ethics Council for pushing his own controversial “brainwash” treatment for stroke victims.

One senior former diplomat in the country, who did not want to to be named, said he did not believe official assertions that no cases had been found. “There’s a tendency to hide or gloss over serious problems in the top levels of the government,” he said. “I’m a bit concerned.”.

Dr Yanri Wijayanti Subronto, a lecturer at Gadjah Mada University in Yogyakarta, said the local health offices had surveillance teams in place and that “this is a system that works”.

But other experts expressed concern over inadequate training of public health practitioners and over public messaging.

Dr Riris Andono Ahmad, director of the Center for Tropical Medicine at Gadjah Mada University in Yogyakarta, said facilities had been set up to handle potential cases but health practitioners have not received sufficient training. “We need to be much more alert,” Ahmad said.

Currently, the policy in Yogyakarta is to ship all samples from potentially affected patients to testing facilities in Jakarta, he said.

“Public awareness of effective prevention measures is not high,” he said. “For instance, there was a lot of panic-buying of masks, but masks only work with people who are already sick. Whereas something that actually works, like washing hands more frequently – I don’t know how many people are really doing it yet.”

Officials in North Korea, another country with close ties to China that has not reported a case, are clearly extremely worried about the danger of an outbreak. Authorities in the country, which has only a rudimentary health system, have effectively put the entire country into quarantine, sealing the borders and stopping all international trains and flights.

Despite these precautions, there have been reports of cases in the north, and in the capital Pyongyang, said Jiro Ishimaru, the head of Osaka-based Asia Press, who runs a secret network of citizen journalists inside North Korea.

“There are lots of rumours flying around that some people have been infected near Dandong, just on the Chinese side of the border, and the Rason special economic zone [on the North Korean side],” Ishimaru told the Guardian. “I have heard from our contacts that some people in Rason have been put in isolation for 20-30 days to prevent an outbreak.”

The border closure has already had a dramatic impact on the economy. “Given the North’s huge dependence on China for things like food, cooking oil and gasoline, there are shortages of daily necessities. People are asking why that is happening, and that’s how they heard about the coronavirus,” Ishimaru said. “The authorities can deny that the coronavirus has reached North Korea, but inflation and shortages are a fact of life.”

Additional reporting by Krithika Varagur in Jakarta and Justin McCurry in Tokyo